Athletic Participation/parental Consent/physical Examination Form (Page 4 of 4) in pdf

Revised March 2013

Page 4 of 4

PART IV -- ACKNOWLEDGEMENT OF RISK AND INSURANCE STATEMENT

(To be completed and signed by parent/guardian)

I give permission for ____________________________(name of child/ward) to participate in any of the following sports that

are not crossed out: baseball, basketball, cheerleading, cross country, field hockey, football, golf, gymnastics, lacrosse, soccer, softball,

swimming/diving, tennis, track, volleyball, wrestling, other (identify sports). ________________________________________________

I have reviewed the individual eligibility rules and I am aware that with the participation in sports comes the risk of injury to my

child/ward. I understand that the degree of danger and the seriousness of the risk varies significantly from one sport to another with

contact sports carrying the higher risk. I have had an opportunity to understand the risk inherent in sports through meetings, written

handouts, or some other means. He/she has student medical/accident insurance available through the school (yes

); has athletic

participation insurance coverage through the school (yes

no ); is insured by our family policy with:

Name of Medical Insurance Company: _______________________________________________________________________

Policy Number: _________________________________

Name of Policy Holder: ______________________________________

I am aware that participating in sports will involve travel with the team. I acknowledge and accept the risks inherent in the sport

and with the travel involved and with this knowledge in mind, grant permission for my child/ward to participate in the sport and travel

with the team.

By this signature, I hereby consent to allow the physician(s) and other health care provider(s) selected by myself or the school to

perform a pre-participation examination on my child and to provide treatment for any injury or condition resulting from participating in

athletics/activities for his/her school during the school year covered by this form. I further consent to allow said physician(s) or heath

care provider(s) to share appropriate information concerning my child that is relevant to participation in athletics and activities with

coaches and other school personnel as deemed necessary.

Additionally I give my consent and approval for the above named student's picture and name to be printed in any high school or

VHSL athletic program, publication or video.

PART V - EMERGENCY PERMISSION FORM

(To be completed and signed by parent/guardian)

STUDENT'S NAME

GRADE ____________ AGE ______ DOB___________

HIGH SCHOOL

CITY ______________________________________

Please list any significant health problems that might be significant to a physician evaluating your child in case of an emergency

______________________________________________________________________________________________________________________________________

Please list any allergies to medications, etc

._______________________________________________________________

__________________________________________________________________________________________________

Is the student currently prescribed an inhaler or Epi-Pen?______List the emergency medication: _____________________

Is student presently taking any other medication? _________If so, what type?

________________________________

Does student wear contact lenses? ____________________ Date of last Tdap or Td (tetanus) shot__________________

EMERGENCY AUTHORIZATION:

In the event I cannot be reached in an emergency, I hereby give permission to physicians

selected by the coaches and staff of

High School to hospitalize, secure proper treatment

for and to order injection and/or anesthesia and/or surgery for the person named above.

Daytime phone number (where to reach you in emergency)

Evening time phone number (where to reach you in emergency)

____________________________

Cell phone

☼►►Signature of parent or guardian

____________ Date__________________

Relationship to student___________________________________________________________________________________________

*Emergency Permission Form may be reproduced to travel with respective teams and is acceptable for emergency treatment if needed.

I certify all the above information is correct__________________________________________

☼►►

Parent/Guardian Signature

The pre-participation physical examination is not a substitute for a thorough annual examination by a student’s primary care physician

Athletic Participation/parental Consent/physical Examination Form Page 4

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